May 7, 2018 – Key Findings from Commonwealth Fund’s 2018 Scorecard on State Health System Performance released:

  • ‘Deaths of despair’ surge. The combined death rate from suicide, alcohol, opioids, and other drugs increased by 50 percent from 2005 to 2016. Rates rose across all states and were up at least twofold in Delaware, Ohio, New Hampshire, New York, and West Virginia.
  • Premature deaths are on the rise. The rate of deaths from treatable medical conditions increased nationally and in two-thirds of states in 2014–15. This reversal of a decade-long downward trend has resulted in more than 3,550 additional premature deaths. In six states — Colorado, Maine, Nebraska, Oklahoma, Vermont, and Wyoming — the increase was greater than 5 percent.
  • Gaps in mental health care are pervasive. Across states, 41 percent to 66 percent of adults with symptoms of a mental illness received no treatment between 2013 and 15. Up to one-third of children needing mental health treatment did not receive it, according to parents’ reports in 2016.
  • Widespread gains in health care access. The scorecard found substantial improvement in people’s overall ability to get and afford health care. Between 2013 and 2016, the adult uninsured rate declined by at least five percentage points in 47 states. And in nearly three-quarters of states, substantially fewer adults skipped needed care because of costs. States that expanded eligibility for Medicaid as allowed by the Affordable Care Act (ACA) saw the biggest declines in their rates of uninsured and cost-related barriers to care.
  • Where you live matters. There are substantial differences in performance among states. Those ranked highest — Hawaii, Massachusetts, Minnesota, Vermont, and Utah — performed about twice as well, on average, than the lowest-ranked — West Virginia, Florida, Louisiana, Oklahoma, and Mississippi.

Additional Scorecard Findings

  • Low-income adults face more difficulty getting care in some states. In Alabama, for example, low-income adults were nearly seven times more likely than those with higher incomes to skip needed care because of costs (33% vs. 5%). But in Pennsylvania, the disparity between high-income and low-income adults was much narrower (17% vs. 9%).
  • Tobacco use continues to decline. Adult smoking rates fell by at least three percentage points in all but four states between 2011 and 2016. States with some of the highest rates, such as Nevada and Oklahoma, saw the largest declines.
  • Improvements in nursing home and home health care. The use of antipsychotic drugs as “chemical restraints” in nursing homes declined in nearly all states between 2013 and 2016. Moreover, the share of home health patients who got better at walking or moving around rose substantially in every state.


The authors note that some lower-ranked states still perform better on certain indicators and that all states can learn from each other. They calculate that if every state achieved top rates of health system performance: 18 million more children and adults would have health insurance; 14 million more would be able to see a doctor when needed; and 89,000 fewer premature deaths from medically preventable causes would occur.

The gains in access to care brought about by Medicaid expansion and the ACA’s insurance marketplace subsidies highlight the role the federal government can play in helping to equalize opportunity across and within states. However, recent gains in access to care may be challenged by the repeal of the ACA’s individual mandate penalties and regulatory changes to state insurance markets currently under way. Additional challenges include high health care costs and eroding affordability for consumers.

Insurance coverage is a necessary but not sufficient condition for improving health care and outcomes. Reversing the disconcerting rise in mortality rates, the authors say, will require tighter integration of services across sectors, as well as better coordination of federal and state efforts to rein in opioid abuse.

With states assuming greater responsibility for the direction of health policy, it will be more important than ever, they say, to continue tracking the performance of state health systems.

The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.